ENT Case Presentation: Chronic Suppurative Otitis Media - Tubotympanic (Safe) Type

PATIENT DETAILS

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

• Otalgia (ear pain at rest - its presence should raise suspicion for intracranial complications)
• Headache (if present, suspect intracranial spread)
• Vertigo or tinnitus (if present, suspect labyrinthine fistula)
• Facial weakness

PAST HISTORY

• Multiple episodes of acute otitis media in childhood
• Recurrent upper respiratory tract infections
• No prior ear surgery

PERSONAL & SOCIAL HISTORY

• Lives in a low socioeconomic setting
• Habit of swimming in a community pool
• Non-smoker, no significant family history

REVIEW OF SYSTEMS

• ENT: No nasal obstruction, no rhinorrhoea, no sore throat
• Neurological: No headache, no neck stiffness
• General: Afebrile, no weight loss

PHYSICAL EXAMINATION

General Examination

• Conscious, cooperative, well-oriented
• Afebrile, vitals stable
• No cervical lymphadenopathy

Ear Examination (Otoscopy/Otomicroscopy)

• External auditory canal (EAC): mild oedema, mucopurulent discharge present
• Tympanic membrane (TM): Central perforation of the pars tensa - this is the hallmark of CSOM tubotympanic (safe) type
  • Perforation is central (does not reach the annulus)
  • Margins are visible and clean
  • Pars flaccida is intact (key distinguishing feature from the unsafe type)
• Middle ear mucosa: appears pale/oedematous; granulation tissue may be visible through the perforation
• No retraction pocket, no scutal erosion, no keratin debris (no cholesteatoma)

Nose/Nasopharynx

• Mild nasal congestion, no polyps
• Eustachian tube orifice: may appear oedematous

Oropharynx

• No tonsillar enlargement, no post-nasal drip

INVESTIGATIONS

1. Audiometry (Pure Tone Audiogram - PTA)

• Conductive hearing loss (CHL) in the right ear, typically affecting low to mid frequencies
• Air-bone gap present (>20 dB)
• Bone conduction thresholds normal (cochlear function intact)
• Conductive loss >30 dB should raise suspicion of ossicular chain erosion - Shambaugh Surgery of the Ear, p. 528

2. Tympanometry

• Type B flat curve on right (perforation present, no compliance measurable)
• Type A on left (normal)

3. Tuning Fork Tests

4. Microbiological Culture & Sensitivity

• Swab from ear discharge
• Most common pathogens in CSOM biofilms: Pseudomonas aeruginosa (most common), Staphylococcus aureus, non-typeable H. influenzae, Moraxella catarrhalis - K.J. Lee's Essential Otolaryngology, p. 446

5. High-Resolution CT Temporal Bones (if indicated)

• Complications suspected (facial palsy, vertigo, headache)
• Cholesteatoma identified or suspected on examination
• Planning for revision surgery Findings in tubotympanic CSOM: middle ear opacification, no erosion of ossicular chain or bony walls (contrast with unsafe type)

6. MRI with contrast

• Reserved for suspected intracranial complications (meningitis, brain abscess, sigmoid sinus thrombosis)

DIAGNOSIS

Key Diagnostic Features (Summary)

PATHOPHYSIOLOGY

1. Failure of middle ear aeration
2. Negative pressure in the middle ear
3. TM retraction (pars tensa affected in tubotympanic type; pars flaccida in atticoantral type)
4. Mucosal oedema - chronic inflammation - granulation tissue formation
5. Collagen breakdown of the TM - perforation

MANAGEMENT

Primary Goal

A. Medical Management (First Line)

• Dry mopping of the ear canal (cotton wick)
• Suction clearance under otomicroscopy
• Removes discharge and biofilm, which improves topical drug penetration

• Fluoroquinolone ear drops (ciprofloxacin 0.3%) - first-line; not ototoxic
• Polymyxin B or neomycin (+/- steroid) combination drops
• Note: biofilms are frequently resistant to topical medications due to their multicellular protective strategies

• Avoid water entry into the ear (cotton wool plug with Vaseline during bathing/swimming)
• Avoid nasal blowing/sneezing with mouth closed

• Management of allergic rhinitis, sinusitis if present
• Nasal decongestants / saline irrigation

• Only for acute exacerbation with signs of spreading infection
• Guide by culture and sensitivity

B. Surgical Management

• Otorrhea refractory to medical treatment after adequate trial
• Tympanic membrane perforation (once ear is dry and stable)
• Symptoms suspicious for complications (vertigo, facial weakness, headache)

• Closure of the TM perforation alone, without ossicular reconstruction
• Indicated when ossicular chain is intact
• Success rate: 60-90%
• Better outcomes if patient can insufflate air through the perforation (Eustachian tube function intact)
• Graft materials: temporalis fascia (most common), tragal perichondrium, fat

• Includes ossicular chain reconstruction when erosion is present

• When cholesteatoma is suspected or granulation tissue is extensive
• Canal wall up (CWU): preserves anatomy, less postoperative care, but slightly higher recurrence
• Canal wall down (CWD): better disease access, open cavity requires lifelong follow-up

COMPLICATIONS (if untreated)

Extracranial

• Acute mastoiditis
• Labyrinthine fistula (vertigo, SNHL)
• Facial nerve palsy
• Bezold's abscess (spread to sternocleidomastoid via mastoid tip)
• Subperiosteal abscess

Intracranial

• Meningitis
• Brain abscess (temporal lobe/cerebellar)
• Sigmoid sinus thrombophlebitis
• Extradural/subdural abscess
• Otitic hydrocephalus

Complications are less common in the tubotympanic (safe) type compared to the atticoantral type, which is why it is labelled "safe" - but this is a relative term and serious complications can still occur.

PATIENT COUNSELLING POINTS

• The disease is chronic and may require long-term management
• Ear precautions (water avoidance) are important to reduce flare-ups
• Surgery (myringoplasty) can close the perforation and improve hearing once the ear is dry
• Regular follow-up is required; annual audiometry is recommended
• Recognise warning signs requiring urgent review: headache, vomiting, vertigo, facial weakness, fever

PROGNOSIS

• Good with appropriate medical therapy and timely surgery
• Myringoplasty success rates are high (60-90%) in a dry ear with good Eustachian tube function
• Risk of recurrence if ET dysfunction is not addressed